Top 5 Things to Know About PT & Health Insurance

By: Blake Anneberg

(Blake is a NYX Mob Member and works as a Patient Representative for a Physical Therapy and Occupational Therapy clinic.)

Healthcare insurance in the States has incredible nuance. As multisport athletes, we pride ourselves in taking care of our bodies and minds. We focus on the goals that allow us to function at a high level in training and racing. So we need to take seriously the issues of health insurance and, in particular, post-injury insurance when it comes to physical therapy. The stress of injury can cloud our minds and judgment, so I’ve provided five key takeaways you should know about so you can focus on getting back into triathlon. 

  1. Know how to contact your current health insurance company. If you are confused or don’t know what you have, just call the phone number on the back of your health insurance card and talk with your company to verify your benefits for either physical therapy or occupational therapy, as they occasionally differ.
  2. Ask your insurance provider these questions to learn about costs and rules: “Do I have a deductible? Is my deductible for PT/OT therapy and is it different from my standard deductible? Do I have a co-pay? If so, what is my co-pay (is it the facility outpatient or inpatient)? Is there a limit on treatment days or dollar amount for treatment? What is my out of pocket maximum? Do I need authorization (like a prescription Rx from a Doctor or Physician’s assistant) or pre-certification for therapy? Does my policy cover Durable Medical Equipment (like crutches)? 
  3. Understand and know when Hospital X, Clinic Y, or Specialist treatment Z might or might not be in your insurance plan network. What does that mean? It might cost you a huge amount of money if you’re getting care out of network from your health insurance or getting treatment that is not covered in your insurance plan. Ask for a TAX ID or NPI (National Provider Identifier) of the clinic or facility so you can call your insurance company and verify if they are in or out of network. Also, ask for the phone number, email or Fax number of specific departments of the clinic/hospital, such as Insurance Verification, Patient Accounts (Billing), Medical Records.
  4. Keep a copy of all your medical records, especially prescription Rx for therapy from doctors and surgeons. Medical records can and do get lost in fax piles. Schedules can be confusing, and missing an appointment can delay your treatment and mess up billing. So have printed copies of appointment times and important documents like prescriptions and even receipts of payment. If you get an unexpected medical bill that you thought you paid, keep them and document what you have paid when you get in touch with the billing department of the facility you had treatment for. Keep up to date health insurance cards in multiple safe spaces, and keep them on your body when doing any kind of training or even racing.
  5. When calling about an insurance or billing issue with a health insurance company, document the calls by taking note of the name of customer support or insurance agent, the tracking ID number of the conversation and the time and date of the conversation. All phone calls should have a tracking number, and use these ID numbers to refer to past conversations you might have to any new agent so you can get them up to speed with the issue at hand.

Hopefully after reviewing the five points above you’ll have an easier time maintaining a positive state of mind during your recovery. Keep recovering, training, and racing hard! 

Guest Author